Healthcare Provider Details

I. General information

NPI: 1376636563
Provider Name (Legal Business Name): CARRIE VENUS FULLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GRAND ST
NEWBURGH NY
12550-5628
US

IV. Provider business mailing address

21 GRAND ST
NEWBURGH NY
12550-5628
US

V. Phone/Fax

Practice location:
  • Phone: 845-562-7244
  • Fax:
Mailing address:
  • Phone: 845-562-7244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR050688-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: